Forms

HHS forms are used every day to perform tasks such as applying for benefits, contracting to provide goods or services, reporting incidents, declaring end of life wishes, and conducting other business.

Title
Form H1105, SNAP Expedited Screening Sheet
Form 3039, HCBS-AMH Program Authorization to Disclose Protected Health Information
Form 2715, Certification of Need for a Non-emergency Psychoactive Medication Regimen
Form 2710, Certification of Need for Major Dental Treatment
Form 2705, Certification of Need for Major Medical Treatment
Form 2700, Application for a Treatment Decision by a Surrogate Consent Committee
Form 1016, PASRR Mental Illness Specialized Services Discussion Checklist
Form 2360, Negative PASRR Evaluation Letter ES
Form 3033, Hemophilia Assistance Program (HAP) Application ES
Form 2805, Youth Empowerment Services (YES) Waiver Comprehensive Waiver Provider (CWP) Selection ES
Form 2809, Youth Empowerment Services (YES) Waiver Verification of Freedom of Choice ES
Form 2811, Youth Empowerment Services (YES) Waiver Letter of Withdrawal ES
Form 1337, CHIP Drug Rebate Agreement
Form 2828, Youth Empowerment Services (YES) Waiver Inquiry List Attestation Inquiry List Attestation
Form 2821, Youth Empowerment Services (YES) Waiver Electronic Visit Verification (EVV) Responsibilities and Additional Information ES